Modifier misuse

Kathy Mills Chang, MCS-PJanuary 31, 2016

As it turns out, the AT modifier does not stand for “all the time”

When the centers for Medicare and Medicaid Services (CMS) told chiropractors that it would only approve claims submitted with the AT (active treatment) modifier, those chiropractors listened. In fact, they listened so well that according to a recent Office of Inspector General (OIG) report, slightly more than 95 percent of Medicare claims submitted in 2013 (the last year studied) were coded with the AT modifier.

The only problem is that almost half of those claims were for what the OIG later determined to be maintenance therapy.

No matter what new issue comes down the pike, from EHR changes to ICD-10 coding, Medicare remains the subject DCs find the most confusing. What’s the difference between active treatment and maintenance care? How does that differ, if at all, from medically necessary care as opposed to clinically appropriate treatment?

Details matter

First, active treatment is for acute conditions or for the stabilization of chronic conditions. CMS considers a patient’s condition acute when “the patient is being treated for a new injury, identified by X-ray or physical exam,” and it can be reasonably expected that chiropractic manipulation will improve or at least arrest deterioration of the patient’s condition.

A chronic condition is a different matter altogether. CMS considers a condition to be chronic when it “is not expected to significantly improve or be resolved with further treatment,” but chiropractic treatment can be reasonably expected to result in some degree of functional improvement. Once that chronic condition is stable and not expected to improve further, any additional treatment is considered maintenance therapy.

And maintenance therapy, according to CMS, is “a treatment plan that seeks to prevent disease, promote health, and prolong and enhance the quality of life” (wellness care) or “therapy that is performed to maintain or prevent deterioration of a chronic condition” (supportive care).

Ironically, maintenance therapy is what most chiropractors advocate for and believe in. DCs sigh, with good reason, over patients who “only show up when it hurts,” and understand that this kind of emergency-room approach to chiropractic is doing both patients and practitioners a disservice. But while maintenance care may be professionally satisfying, arguably advisable, and clinically appropriate, it isn’t considered medically necessary.

Therefore, Medicare won’t cover it. Most third-party payers won’t, either. Maintenance therapy is vital to wellness, and you should continue to render it. You also must prepare your patients to pay for it out of pocket— and educate them about why it’s important to make maintenance therapy a part of their budget.

It would be one thing if getting your codes wrong just meant a denied claim. And that, in and of itself, is no small problem. Denied claims can grind revenue to a halt. But an even bigger problem is that intentionally or even unknowingly miscoding your claims, no matter how strong your conviction that the patient deserved covered treatment or the degree of your misunderstanding of the AT modifier, puts you at high risk of records reviews and audits.

Based on its findings over the past few years, the OIG is recommending that CMS scrutinize chiropractors more closely and even launch oversight programs for chiropractors with high error rates. If you’re billing the highest CMT codes possible (98942, for example) and appending the AT modifier aimlessly, you’re waving a huge red flag from the roof of your practice. And the consequences for red- flag behavior grow higher every year.

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which became law in April 2015, contains provisions for the oversight of Medicare chiropractic services, including requiring preauthorization for services provided by chiropractors with aberrant billing or high rates of denial. It remains to be seen what that will look like in reality, but the OIG is hoping to put such oversight into place by 2017 at the latest, making the next year a critical one for getting your documentation in order and your coding in compliance.

So what constitutes “aberrant billing,” according to the OIG? The government entity uses four primary measures:

Treatment “suggestive of maintenance therapy”

To the OIG, that means a high number of claims per beneficiary per episode of care. The OIG says the average is, believe it or not, eight. Some flagged claims average as high as 25.

Potentially up-coded claims. The OIG says that in its opinion, only about 10 percent of all paid chiropractic services should be for the highest code, 98942. But its previous investigations find a much higher percentage of 98942s billed—and it believes almost half of them were up-coded.

Sharing of beneficiaries. A high average of beneficiary sharing with other DCs and practitioners, according to the OIG, increases incidences of fraud, including medical identity theft and kickbacks.

A high or unlikely number of services per day. What strikes the OIG as an unreasonable number of services billed in one day suggests, it says, diminished quality of care at best, and outright misrepresentation of services rendered (i.e., fraud) at worst.

Time and attention

Most chiropractors are not intentionally fraudulent. The OIG considers only 2 percent of the coding “outliers” it investigated to be willfully breaking the law. Most chiropractors are trying to do the best they can with what little time they have. It’s easy to throw a five spinal region adjustment code onto a claim form, tack on the AT modifier, and call it good. It’s even easy to justify treating all five regions, and many DCs, especially those who use specialty adjustment techniques, advocate that this is good practice.

The bottom line is that it doesn’t matter what you or any other chiropractor thinks. The rules and regulations are federally mandated and enforced.

Appropriate documentation and coding practices aren’t complicated to learn, but they do require time and attention. Your documentation should accurately and compellingly make its case for active treatment of an acute or improvable chronic condition, and tell the story of a beginning, a middle, and an end of an episode of care—preferably in eight visits or less. Then, make sure the code(s) you’ve selected match up.

AT means active treatment. Use it all the time, and you’re sending the wrong signal—one that says you either don’t know or don’t care what you’re doing. The consequences, quite simply, aren’t worth it.

Kathy Mills Chang, MCS-P, CCPC, is a certified medical compliance specialist (MCS-P) and, since 1983, has been providing chiropractors with reimbursement and compliance training, advice, and tools to improve the financial performance of their practices. She leads a team of 16 at KMC University and is known as one of the profession’s foremost experts on Medicare. She or any of her team members can be reached at 855-832-6562, info@kmcuniversity.com, or through kmcuniversity.com.